Case:Maxwell
Thumbnail Maxwell BG at DX 512. *Regulation and ulitmately remission were the result of using BCP PZI BID, removing all dry food, and changing feeding schedule. Regulation in 3 months; remission in 5 months. *Currently negative for clinical symptoms, including ketones. Clinical symptoms at DX and beyond were PU/PD, neuropathy, and lethargy. *Other known health problems: Now early chronic renal failure. Also, fPLI testing shows a highly diseased pancreas. *Sadly, Max was DX with an inoperable pancreatic-origin cancer in late February 2007, and was euthanized at home on March 9, 2007. Typical blood glucose levels Listings and logs of Max's BG readings since on BCP PZI are available through this pageMax's BG Lists & Logs on BCP PZI Insulin. Max's BG levels without exogenous insulin are the same or slightly higher than they were in the last month of insulin shots--in the 80-170 range. Other treatment information When Max was on insulin, I hometested regularly, at least every preshot and some spot checks, with a LifeScan One Touch Ultra glucometer. In remission, I tested occasionally. I also used Ketodiastix that consistently showed no ketones and, after regulation, no urinary glucose. Max had never been on steroids. He did have neuropathy and balance problems and he did take (and sometimes continues to take) Methyl B-12 for that. A dental procedure he had in October 2005 showed dental disease and one tooth was extracted, but the procedure had no effect on his BG readings. I had one vet about 1 hour away who was Max's diabetic case manager, while a nearby vet served as GP and did blood draws and urine samples and performs other procedures, like dentals and annual exams. Max had a semi-annual senior blood panel/urinalysis and a baseline fPLI test (for pancreatic function) in late January 2006. Results of those and followup tests: early chronic renal failure (CRF) and a through-the-roof fPLI result. Vet did not want to repeat the fPLI; vet said it was likely that the pancreas is extremely diseased, but there is enough of it functioning to produce the indogenous insulin Max needs. We tried new foods to lower the protein a touch and reduce phosphorus as much as possible, but there was s that whole crabby-I-hate-that-new-food thing going on. And, as is common with CRF, Max's blood pressure was elevated, so he was on blood pressure medication. There were 3 other cats here at the time Max was diabetic--Ennis (Max's littermate) and Lily and Bailey, two borderline feral cats. All four cats were indoor cats. Insulins used When first DX, Max received 1 unit of U100 compounded PZI (Humulin R and PZ) once a day (SID) in the AM. The vet stair-stepped this up slowly (higher AM one week and then PM to match the next week). Although we eventually got to 2.5 units BID (and did a curve on Max's AM cycle when he was on 3 units AM and 2 units PM that showed he was responding to the 3 units), I felt I would not be happy with the compounded PZI long term and switched to BCP PZI. We started back over at 1.2 units. Max was on as high as 3.2U BID BCP PZI. After I took his dry food away, his BG levels and insulin needs tumbled. He eventually settled into dosages of .8U AM and .6U PM (different because he eats more during the AM timeframe). Most recent curve A graph of Max's January 8, 2006, curve without insulin (that is, on endogenous insulin alone), is hereMax's Curve On His Own Insulin. In that file also is a graph of a curve of Max's littermate, Ennis, at the same time under the same conditions. I used Ennis as a "control" to determine whether Max's readings might be considered "normal" compared to another cat with similar genetic makeup. Both cats were fed small amounts of wet food at least after each test--that is, at least every 2 hours. Analysis Over a 24-hour period, Max averaged 120, with a range of 79 to 171. Over a 12-hour period, Ennis averaged 132, with a range of 101 to 158. Although I would like to see Max's curve on endogenous insulin lower, it appears that this may well be his "normal" or non-diabetic range. I want to thank Lisa and Merlyn for their incredible curves of a diabetic cat in remission. Past curves Graphs and analysis of Max's November 18, 2005, and December 14, 2005, curves are here. Effect of food Food had a profound effect on Max's BG levels and thus on our treatment plan. Max ate much more during the AM hours than during the PM hours. Consequently, when he was receiving shots BID, his AM dosage of insulin was higher than his PM dosage. Max had always been a dry food eater, and I switched him to EVO, a low-carb dry food, at DX and tried to get him to eat as much low-carb Fancy Feast (wet food) as possible. Archetype sometimes mashed into wet food as a teaser. I only left food down until +6 of each cycle. I took away Max's EVO on 11/6/05. That move alone broke his glucose toxicity and dropped the BG levels on his AM cycle about 150 points. However, the 11/18/05 curve still showed a huge food spike (about 150 points) after breakfast. It took him until +5 to regain PS levels. As an experiment, I started breaking his breakfast into three parts: +11, +1, and +3. I tested the results 3 days later and they were remarkable. His initial food spike was only 63 points and he regained his PS level by +3, and had the lowest nadir since on insulin: 53 at +7. Again, I only left food down until +6 of both cycles. I am now free feeding small amounts of FF, little dollops as he wants them, as another attempt to smooth his curve. The results of that show in the curve on 12/14/05. While he was still on BID insulin, he showed very little effect of food. As Max's pancreas started sputtering, a little food seemed to drop his BG levels. Regulation/Remission In December 2005, Max's BGs readings started to get very low. He would be below renal threshold for most or all of each day. He then started to have some SID days or near SID days, but they took him near or into the 200s. Max went his first 48 hours without exogenous insulin from 12/21/05 PM to 12/23/05 PM. During that time, he rode mostly in the 130s/140s. Although I wanted to keep him as low as possible with insulin shots PRN, it was difficult to know when to shoot him because at times he was helping out and that would drive his levels with an insulin shot very low. I also started to find him getting a food dip instead of a food spike: his pancreas dumps insulin in response to the food. So my process became one of testing him prefood, giving him dollops of food every hour until he'd had enough and got the sleepies, and then testing him again to see whether he needed a shot. Usually he would be lower and I could skip the shot. There would be times, however, that I found his prefood number very high (in the 180s--I suspected dawn phenomenon) and I gave a token shot. Once I curved Max on 1/8/06, I realized that I had not added much to his regulation with the last couple of weeks of insulin shots. The BG levels I had been seeing from him, including his higher "dawn" numbers, is just his normal. (Note that the 1/8/06 curve does not demonstrate Max's higher dawn numbers because he was wide awake during the pre-dawn hours because of the curve process.) My observations about BCP PZI Fundamentals. A set dose of PZI takes 7-10 days to "settle." By "settle," I mean it finally finds it's groove and becomes its most effective in terms of lowering BG levels. During that "settling" period, the curve will become flatter. What I mean by that is when you first start a dose, you may get some drops at "peak" (sometimes very significant drops), but the longer on the dose (up to a point), the more the drop will lessen. If the dose is close to right, the flattening of the curve will not only raise the peak, but it will lower the PSs. (If the dose isn't close to right, the settling will raise the peak, but the PSs won't lower and you just end up with a high flat curve.) If you are close to the right dose, the PSs start progressively lowering. The lowering is a trend thing, not a linear thing--meaning that is that each successive PS is not lower than the one before, but if you stand back and look at the numbers fuzzy eyed over time they generally are moving down. When you start seeing that downward trend in PSs with flat curves, that's when you know you are near the right dose. Because the curve is flat, the only thing that set dose can do to improve the situation is to lengthen the duration (the amount of time the insulin stays in the body working). That's when the entire curve (which remains flat) starts moving down and giving you not only continuing, progressively lower PSs but also lower numbers throughout the day. When you start seeing that, you should be aware that each new shot you are giving is more and more "overlapping" the previous shot that is still in his body working. Panceas kicking in. If a cat is going to honeymoon, when you see the curves flatten and lower is when you need to really start paying attention. If the cat is held at or below renal threshhold (200-250) for most or all of the day, his pancreas can start to heal (if it's going to) and start to help the downward progression of the numbers. With Max, the biggest sign that his pancreas was helping was that his curve started to get steep again. Meaning that his peaks began becoming lower in relation to his PSs than they were previously. See the graph of Max's 12/14/05 curve. That was relatively flat, dips of at the most ~80 points at ~+7. It became clear to me that his pancreas was kicking in when less than a week later Max was getting dips of more than 100 points at +4. Those extreme dips when Max's pancreas started kicking in were not scary but manageable because after so much experience with his diabetes and with this insulin, I knew he wasn't hypo prone. (I also knew he wasn't hypo proof and I knew how to handle hypo!!) So I could ride those low numbers out by watching him closely, and he would bottom out and stay there or rise very slowly over several hours. Rebound. There is an article about rebound here. There are two types of rebound: chronic and acute. Both are caused by the same thing: too much insulin. Max never got into chronic rebound because I practiced the start low go slow approach and allowed plenty of time for and closely analyzed the settling (as agonizing as it was to sit on my hands when he was in the high flats 300s). However, the darling, although not hypo-prone was, in the right set of circumstance, prone to acute rebound. All of a sudden Max's body would say: Stop the merry-go-round, I have to get off, this is too much! The message can be subtle or overt but you should be watching for it with your cat if s/he is starting to respond in spurts to the PZI. With Max, I was watching because I had recently taken his EVO away, expecting that his dose might be too high and that he might rebound. When I took away the EVO, I dropped Max's dose a little from 3.2U to 2.8U to "compensate." 4 cycles later, on a night cycle, Max gave me a lower than normal PS of 153, I waited an hour until he got to 331 (closer to what I was used to), and shot. At +6 he was at 364 and at +11 388. This was NOT like Max to rise from PS through the night or to be anywhere near that high at +6. I guessed that something happened between his shot and +6 that sent him too low or low too fast. I dropped his dose to 2U the next morning and we were on a downhill slide on dose and improved numbers ever since. There are other manifestations of acute rebound, for those who don't compulsively test at least every 6 hours like I tend to do. The biggest one is a huge jump from one PS to the next (like 200 points or more). As unintuitive as it may seem, when that sort of thing happens, my advice is to CUT the next 2 or maybe more doses, because the cat is starting to show insulin sensitivity. And you want to take advantage of that; not put the cat into a chronic rebound situation. Cancer After Maxie's vet discovered a mass in his abdomen through palpation, and suspected a liver tumor, I took Max to a specialty clinic for an ultrasound. The result was that Max had a 10.1cm inoperable pancreatic-origin tumor that had wrapped itself around the portal vein, invaded the liver, and likely was compromising the spleen. The tumor also was "bleeding out." I chose palliative care, and sent Max peacefully on his way 17 days after the initial "probable" DX. I have come to understand that pancreatic-origin cancer in cats is rare, and also that chemo is generally ineffective. I also have come to understand that the extremely high results from his fPLI test likely were an early indicator of his cancer. Questions?? You can leave me questions about Max at my talk page. December 2005. References Category:BCP PZI casesCategory:PZI casesCategory:Dental infection casesCategory:Feline casesCategory:Glucose toxicity casesCategory: Male casesCategory:Neuropathy casesCategory:Regulated casesCategory:Remission casesCategory:Feline male casesCategory:Feline regulated casesCategory:Feline neuropathy cases Category:Feline glucose toxicity cases